Skip to content

Case 6:  Diabetes and medications

68 year old obese man who has chronic pain from his osteoarthritis (on co-codamol 8/500 with some extra codeine at night) and depression (for which he’s on paroxetine), chronic reflux (which cimetidine controls well) and dermatitis (for which he has betamethasone, oilatum and a nightly chlorpheniramine), comes as his ‘diet controlled’ Diabetes is no longer controlled and his friend suggests he should be on Metformin.
Do you think that each of his medications is justified individually?

Many of his meds are not formulary first choices, There is little evidence for codeine for chronic pain. Cimetidine can be bought OTC which may make it popular with some prescribers. Some patients are worried by the total removal of acidity with PPIs. Paroxetine is commonly used, though not first choice of the SSRIs generally. Chlorpheniramine is quite sedating. These over prescribing issues cause planetary health harm and contribute to the 60% of primary care’s carbon footprint coming from medication. 

Can you guess which order they were added to the prescription?

Cascade prescribing describes the reality of meds being added to manage the side effects of earlier meds. Possibly his weight may have impacated his joint pain. The codeine given for pain relief made him less energetic (and less active) reducing his social life and leading to the Paroxetine, which is known to exacerbate acid reflux and so the cimetidine is added. At any point along the line his skin became itchier and so the chlorphenamine was added.

What side effect pattern do these medications have in common?

Anticholinergic burden (ACB)

(codeine =1, paroxetine 3, cimetidine 2, chlorphenamine 3, metformin 1)


The higher the ACB score the higher the risk of mortality and effects on cognitive function. Clinicians prescribe more to those who are older and lower social class.

What ways could we support him to manage his conditions better? 

There is evidence for the effectiveness of green (outside in contact with the natural world) or blue (involving water) therapies as part of social prescribing to manage mild to moderate depression. 

Working with him to look at diet options which might help him to reduce his weight is also appropriate (as weight is potentially a cause of his issues).

NB there are financial issues with ideal diets like EAT Lancet diet as the proportion of disposable income involved means this is unaffordable in its entirety for many poorer people in UK.